Urethrotomy

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Urethrotomy
URETROTOMO.jpg
Urethrotome
ICD-10-PCS 58.0
OPS-301 code 5-580

A urethrotomy is an operation which involves incision of the urethra, especially for relief of a stricture. It is most often performed in the outpatient setting, with the patient (usually) being discharged from the hospital or surgery center within six hours from the procedure's inception.[ citation needed ]

Contents

Urethrotomy (also referred to as DVIU, or Direct Visual Internal Urethrotomy) is a popular treatment for male urethral strictures. However, the performance characteristics are poor. Success is less than 9% for the first or subsequent urethrotomies. Most patients will be expected to experience failure with longer followup and the expected long-term success rate from any urethrotomy approach is 0%. [1] Beginning in 2003, several urology residency programs in the northeastern section of the United States began advocating the use of urethrotomy as initial treatment in the young stricture patient, versus urethral dilatation. It is theorized that the one-to-two years of relief from stricture disease will allow the practitioner and the patient to plan the most effective treatment regimen without having the concern that undergoing multiple dilatations cloud the judgment of the patient. Furthermore, should urethroplasty be selected by the patient, minimal scar tissue will have developed at the site of the stricture in the urethrotomy patient, as opposed to the patient who had undergone the more conventional (dilatation) route.[ citation needed ]

The procedure

Now the diagnosis has been confirmed by either cystoscopy or a prior urethrography, the patient is placed in the lithotomy position, and the urinary meatus is cleansed with an appropriate surgical cleansing agent (scrub), usually containing Povidone-iodine, then surgically draped. An IV antibiotic or other anti-infective medication is administered in conjunction with intravenous normal saline, and allowed to run until administration of the prescribed dose is completed. Most often, procedural sedation will be the chosen adjunct to patient comfort, and the patient will have received intravenous anxiolytic medication at sometime prior to, or during the surgical preparation. This medication is usually a benzodiazepine, often, diazepam or midazolam is employed. The urological surgeon or anesthesia practitioner may also choose to administer a narcotic analgesic such as fentanyl citrate, depending on the level of discomfort anticipated by the surgeon. In some cases, usually where longer strictures are present, a rapidly metabolized hypnotic agent such as propofol may be selected, as this allows for the immediate induction of short-term general anesthesia (note:endotracheal intubation will also be necessary if general anesthesia is administered). Constant monitoring of vital signs including pulse oximetry, cardiac monitoring (ECG), body temperature and blood pressure are carried out by the anesthesia practitioner until the patient is discharged post-operatively to the post-surgical recovery unit. [2]

A topical anesthetic, usually viscous lidocaine is instilled into the urethra, and a penile (crown) clamp is applied for at least five minutes, then removed immediately prior to the insertion of a cystoscope equipped with a transurethral injection system containing a local anesthetic (most often 2% (plain) lidocaine, or 0.5% (plain) bupivicaine). The urological surgeon will inject the anesthetic at the twelve o'clock, four o'clock, and eight o'clock positions at the face of the stricture using infiltrative technique, and ensuring that the entire length of the stricture has been medicated. The cystoscope (and injection system) will be withdrawn, and sufficient time will be allowed for the local anesthetic to take effect (usually five-to-ten minutes). [2]

At this time a rigid urethrotome or a flexible cystoscope/urethrotome combination will be inserted and guided to the face of the stricture and a small blade towards the tip of the instrument will be deployed using a trigger mechanism to cut the stricture at locations determined by the surgeon. Upon completion of the internal incision(s), the instrument is withdrawn and an appropriately sized Foley catheter will be inserted through the repair and into the urinary bladder, and locked into place by filling its balloon (positioned inside of the bladder near the urethral junction) with sterile water. The Foley catheter serves two purposes, first, it provides drainage of the urine produced in the kidneys, and secondly, it secures the incised areas, holding them open for three to seven days to permit thorough healing of the urethra. The catheter is then attached to a urinary catheter drainage system (large bag or leg bag) via clear polypropylene tubing. [3]

Post procedural care

Prior to discharge from the surgical facility, the patient will be instructed on proper care of the urinary drainage system, how to monitor for signs of infection, and the limitations of physical activity necessary for the safety of the patient, and the success of the procedure. A course of oral antibiotics or anti-infective agents will be prescribed. Additionally, a urinary analgesic such as phenazopyridine or urinary analgesic/anti-spasmodic combination containing methanamine, methylene blue, and hyoscyamine sulfate will be offered. Palliative medications may sometimes be prescribed, but are often not necessary because there is usually minimal discomfort post-procedure. [4]

A few steps can be taken before surgery to reduce the discomfort of recovery. It is suggested to wear loose fitting undergarments after the procedure as there is a chance of having a catheter after the procedure. Men's cotton boxers work well for both comfort and containing any bleeding that may occur. (Note: bleeding after a urethrotomy is expected and can last up to 48 hours.) Purchasing cheap black or dark grey undergarments can help with post-surgery anxiety as light-colored undergarments can make the bleeding appear worse than it actually is and the undergarments can be thrown out after use. Additionally, applying water-based lubricant to the catheter and allowing it to run down and coat the opening of the urethra will prevent the catheter from rubbing and irritating the urethral opening. Lastly, preparing lean meals before surgery such as grilled chicken or salad is a good idea to ease recovery for the 48 hours after surgery.[ citation needed ]

Post surgical evaluation and care

The surgeon will remove the catheter three to seven days after the surgery is completed. A baseline uroflowmetric study will be performed, and the patient will be instructed to return in thirty days for a follow-up evaluation. This evaluation will include another uroflowmetric study and a complete urinalysis. Follow-up visits are scheduled at six-month intervals, as determined by the practitioner responsible for the treatment plan. [4]

It has become common practice for urologists to prescribe self-catheterization at weekly intervals for the post-urethrotomy patient. After voiding, and using sterile technique, a lubricated Foley catheter is passed into the urethra, through the surgically modified area, into the bladder and allowed to remain in place for up to ten minutes. The catheter is then carefully withdrawn and discarded, and the patient is then instructed to void as soon as possible (this helps to cleanse the urethra of any blood or water-based lubricant and lessen the possibility of infection). Although no formal studies have been conducted, there does appear to be an improvement in intervals between subsequent urethrotomies and an improvement in uroflowmetric data for most patients who have undergone this regimen. [5]

Controversy

Many leading urologists in the United States consider urethrotomy to be (almost) totally ineffective at providing long-term resolution of urethral stricture disease, and advocate excision of the damaged area followed by either a surgical anastomosis of the (now) patent urethral ends, or a grafting of similar tissue harvested from elsewhere on the patients body. [6]

The cost-effectiveness of the procedure has come into question. In the May, 2006 issue of "Urology", a study undertaken by the Urology Department of the University of Washington essentially concluded that there is a statistical correlation between the length of the stricture and the cost versus benefit ratio of subsequent urethrotomies performed prior to the performance of urethroplasty in males suffering from bulbar strictures. [7]

Urethrotomy is a much simpler operation requiring much less recovery time and that open surgical excision of a simple, short stricture even if initially successful may still require the same repeated post operative self dilation that the simpler urethrotomy often requires. It may be that a longer complicated stricture may be better treated with an open procedure while the shorter simpler one with a urethrotomy.[ citation needed ]

See also

Related Research Articles

Urology Medical specialty

Urology, also known as genitourinary surgery, is the branch of medicine that focuses on surgical and medical diseases of the urinary-tract system and the reproductive organs. Organs under the domain of urology include the kidneys, adrenal glands, ureters, urinary bladder, urethra, and the male reproductive organs.

Cystoscopy Medical procedure; endoscopy of the urinary bladder via the urethra

Cystoscopy is endoscopy of the urinary bladder via the urethra. It is carried out with a cystoscope.

Urinary catheterization Insertion of a catheter through the urethra to drain urine

In urinary catheterization a latex, polyurethane, or silicone tube known as a urinary catheter is inserted into the bladder through the urethra. Catheterization allows urine to drain from the bladder for collection. It may also be used to inject liquids used for treatment or diagnosis of bladder conditions. A clinician, often a nurse, usually performs the procedure, but self-catheterization is also possible. A catheter may be in place for long periods of time or removed after each use.

Urethral stricture Medical condition

A urethral stricture is a narrowing of the urethra caused by injury, instrumentation, infection, and certain non-infectious forms of urethritis.

Bladder stone Concretion of material in the urinary bladder

A bladder stone is a stone found in the urinary bladder.

Hypospadias Medical condition

Hypospadias is a common variation in fetal development of the penis in which the urethra does not open from its usual location in the head of the penis. It is the second-most common birth abnormality of the male reproductive system, affecting about one of every 250 males at birth. Roughly 90% of cases are the less serious distal hypospadias, in which the urethral opening is on or near the head of the penis (glans). The remainder have proximal hypospadias, in which the meatus is all the way back on the shaft of the penis, near or within the scrotum. Shiny tissue that should have made the urethra extends from the meatus to the tip of the glans; this tissue is called the urethral plate.

Hematuria Medical condition

Hematuria or haematuria is defined as the occurrence of blood or red blood cells in the urine. The word hematuria is derived from Greek haima (αἷμα) "blood" and ouron (οὖρον) "urine". Hematuria can be visible to the naked eye and may appear red or brown, or it can be microscopic. The origin of the blood that enters and mixes with the urine can arise from any anatomical site within the urinary system, including the kidney, ureter, urinary bladder, and urethra, and in men, the prostate. Common causes of hematuria include urinary tract infection (UTI), kidney stones, viral illness, trauma, bladder cancer, and exercise. The underlying causes of hematuria can be divided into glomerular and non-glomerular causes, referring to the involvement of the glomerulus of the kidney. Notably, not all red urine is hematuria. Other substances such as certain medications and foods can cause urine to appear red. Menstruation in women may also cause the appearance of hematuria and may result in a positive urine dipstick test for hematuria. Additionally, a urine dipstick test may be falsely positive for hematuria due to other substances in the urine such as myoglobin during rhabdomyolysis. A positive urine dipstick test should be confirmed with microscopy, where hematuria is defined by three of more red blood cells per high power field. When hematuria is detected, a thorough history and physical examination with appropriate further evaluation can help determine the underlying cause.

Urinary retention Inability to completely empty the bladder

Urinary retention is an inability to completely empty the bladder. Onset can be sudden or gradual. When of sudden onset, symptoms include an inability to urinate and lower abdominal pain. When of gradual onset, symptoms may include loss of bladder control, mild lower abdominal pain, and a weak urine stream. Those with long-term problems are at risk of urinary tract infections.

Transurethral resection of the prostate Surgical procedure to perform a prostatectomy

Transurethral resection of the prostate is a urological operation. It is used to treat benign prostatic hyperplasia (BPH). As the name indicates, it is performed by visualising the prostate through the urethra and removing tissue by electrocautery or sharp dissection. It has been the standard treatment for BPH for many years, but recently alternative, minimally invasive techniques have become available. This procedure is done with spinal or general anaesthetic. A triple lumen catheter is inserted through the urethra to irrigate and drain the bladder after the surgical procedure is complete. Outcome is considered excellent for 80–90% of BPH patients. The procedure carries minimal risk for erectile dysfunction, moderate risk for bleeding, and a large risk for retrograde ejaculation.

Foley catheter Medical device

In urology, a Foley catheter is a flexible tube that a clinician passes through the urethra and into the bladder to drain urine. It is the most common type of indwelling urinary catheter.

Mitrofanoff procedure

The Mitrofanoff procedure, also known as the Mitrofanoff appendicovesicostomy, is a surgical procedure in which the appendix is used to create a conduit, or channel, between the skin surface and the urinary bladder. The small opening on the skin surface, or the stoma, is typically located either in the navel or nearby the navel on the right lower side of the abdomen. Originally developed by Professor Paul Mitrofanoff in 1980, the procedure represents an alternative to urethral catheterization and is sometimes used by people with urethral damage or by those with severe autonomic dysreflexia. An intermittent catheter, or a catheter that is inserted and then removed after use, is typically passed through the channel every 3–4 hours and the urine is drained into a toilet or a bottle. As the bladder fills, rising pressure compresses the channel against the bladder wall, creating a one-way valve that prevents leakage of urine between catheterizations.

Radical retropubic prostatectomy

Radical retropubic prostatectomy is a surgical procedure in which the prostate gland is removed through an incision in the abdomen. It is most often used to treat individuals who have early prostate cancer. Radical retropubic prostatectomy can be performed under general, spinal, or epidural anesthesia and requires blood transfusion less than one-fifth of the time. Radical retropubic prostatectomy is associated with complications such as urinary incontinence and impotence, but these outcomes are related to a combination of individual patient anatomy, surgical technique, and the experience and skill of the surgeon.

A ureteral stent, or ureteric stent, is a thin tube inserted into the ureter to prevent or treat obstruction of the urine flow from the kidney. The length of the stents used in adult patients varies between 24 and 30 cm. Additionally, stents come in differing diameters or gauges, to fit different size ureters. The stent is usually inserted with the aid of a cystoscope. One or both ends of the stent may be coiled to prevent it from moving out of place; this is called a JJ stent, double J stent or pig-tail stent.

Neurogenic bladder dysfunction, or neurogenic bladder, refers to urinary bladder problems due to disease or injury of the central nervous system or peripheral nerves involved in the control of urination. There are multiple types of neurogenic bladder depending on the underlying cause and the symptoms. Symptoms include overactive bladder, urinary urgency, frequency, incontinence or difficulty passing urine. A range of diseases or conditions can cause neurogenic bladder including spinal cord injury, multiple sclerosis, stroke, brain injury, spina bifida, peripheral nerve damage, Parkinson's disease, or other neurodegenerative diseases. Neurogenic bladder can be diagnosed through a history and physical as well as imaging and more specialized testing. Treatment depends on underlying disease as well as symptoms and can be managed with behavioral changes, medications, surgeries, or other procedures. The symptoms of neurogenic bladder, especially incontinence, can have a significant impact on quality of life.

Urethral cancer Medical condition

Urethral cancer is a rare cancer originating from the urethra. The disease has been classified by the TNM staging system and the World Health Organization.

Urethroplasty is the repair of an injury or defect within the walls of the urethra. Trauma, iatrogenic injury and infections are the most common causes of urethral injury/defect requiring repair. Urethroplasty is regarded as the gold standard treatment for urethral strictures and offers better outcomes in terms of recurrence rates than dilatations and urethrotomies. It is probably the only useful modality of treatment for long and complex strictures though recurrence rates are higher for this difficult treatment group.

Prostatic stent Type of stent

A prostatic stent is a stent used to keep open the male urethra and allow the passing of urine in cases of prostatic obstruction and lower urinary tract symptoms (LUTS). Prostatic obstruction is a common condition with a variety of causes. Benign prostatic hyperplasia (BPH) is the most common cause, but obstruction may also occur acutely after treatment for BPH such as transurethral needle ablation of the prostate (TUNA), transurethral resection of the prostate (TURP), transurethral microwave thermotherapy (TUMT), prostate cancer or after radiation therapy.

Urethrostomy

Urethrostomy is a surgical procedure that creates a permanent opening in the urethra, commonly to remove obstructions to urine flow. The procedure is most often performed in male cats, where the opening is made in the perineum.

Urogynecology or urogynaecology is a surgical sub-specialty of urology and gynecology.

Surgery for benign prostatic hyperplasia Type of surgery

If medical treatment is not effective, surgery may need to be performed for benign prostatic hyperplasia.

References

  1. ↑ Santucci R, Eisenberg L (May 2010). "Urethrotomy has a much lower success rate than previously reported". J. Urol. 183 (5): 1859–62. doi:10.1016/j.juro.2010.01.020. PMID   20303110.
  2. 1 2 Nagle, G.M.; Bollinger, J.R. (1997). Genitourinary Surgery . Mosby. ISBN   9780815170297 . Retrieved 2015-04-12.
  3. ↑ "Smith's Textbook of Endourology, By Arthur D. Smith, Gopal H. Badlani MD, Demetirus H. Bagley MD, Ralph V. Clayman, Steven G. Docimo MD". PMPH - USA.
  4. 1 2 Genitourinary surgery, Gratia M. Nagle, R.N., B.S.N., James R. Bollinger, M.D. F.A.C.S. Mosby, 1997. 1997. ISBN   9780815170297.
  5. ↑ "Cystoscopy and Optical Internal Urethrotomy Peri-Op Instructions: Urologic Surgical Associates of Delaware". usadelaware.com. Retrieved 2015-04-12.
  6. ↑ "Long-term Follow up for Excision and Primary Anastomosis for Anterior Urethral Strictures" (PDF). Indiana Purdue University Department of Urology.
  7. ↑ "Cost-effectiveness of direct vision urethrotomy versus urethroplasty for short bulbar urethral strictures". University of Washington - Seattle, Department of Urology. 2006-08-17.
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